Shingles in the young; low back pain; cannabis and pain: Upstate Medical University's HealthLink on Air for Sunday, Nov. 3, 2024

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a microbiologist shares research on shingles, which is affecting more young people.

Jennifer Moffat, PhD: ... If you've had chickenpox or been vaccinated against it, the only way you can get shingles is from the viruses already inside you. ...

Host Amber Smith: A physical therapist discusses causes and treatments for low back pain.

Steven Lounsbury, DPT: ... Our spines are made to move, and we feel better with movement. I often teach my patients the phrase that 'movement is medicine" ...

Host Amber Smith: And a pair of researchers explain how cannabis use may reduce a person's tolerance for pain.

Yanli Zhang-James, MD, PhD: ... It's becoming increasingly widely accepted and considered relatively safe drugs to use for pain, but people should still be aware that it comes with certain risks. ...,

Host Amber Smith: All that, along with The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, we'll look at low back pain causes and treatments. Then, how cannabis use may actually reduce a person's pain tolerance. But first, what's important to know about shingles?

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

A painful infectious disease that usually impacts people over 50 is showing up in younger adults. So today I'm talking about possible reasons for this with Dr. Jennifer Moffat. She's an associate professor of microbiology and immunology at Upstate, and she studies the Varicella zoster virus, which causes chickenpox and shingles.

Welcome back to "HealthLink on Air," Dr. Moffat.

Jennifer Moffat, PhD: Well, thank you for the invitation, Amber. I'm delighted to be here today to talk to you about the virus, the diseases and how we can treat them and prevent them.

Host Amber Smith: Well, I'd like to start by asking you to tell us about the Varicella zoster virus. When and how was it discovered?

Jennifer Moffat, PhD: It was known to humanity for a long time. In fact, the word "shingles," which it causes, comes from a Roman word, "cingulum," for the belt. And so it was known as "the belt of fire." In fact, that is often found around people's waist and chest. So it's been with humans for a long time, but it was in the 1950s that we were able to culture it and grow it.

And that was done by Thomas Weller in England.

Host Amber Smith: So how is it similar to or different from other viruses? What distinguishes it?

Jennifer Moffat, PhD: What is really important about it is that it can infect us and stay in our bodies for life. It is "latent"; we say latent, meaning it's hidden in our nervous system for our whole life.

And this is a property of other viruses too, but Varicella zoster virus is also famous for being one of the most contagious viruses, especially in childhood. Chickenpox spreads rapidly right through a classroom, and shingles infections can trigger another outbreak of chickenpox in kids.

Host Amber Smith: So does it infect just humans, or other animals, too?

Jennifer Moffat, PhD: It is uniquely infecting humans. It cannot infect any other animal, but other animals have their own version. There's a monkey chickenpox, but it's not the same virus.

Host Amber Smith: And I understand it spreads easily from person to person. But is it airborne, or is it on surfaces?

How does it spread?

Jennifer Moffat, PhD: It spreads through our breath droplets, our respiratory spread. So when a person has chickenpox, some of the virus is growing in their throat, and it can then spread through talking, playing and so on, in the air. And when a person has shingles, it was just recently discovered that the saliva contains the virus. Even though the rash may be on your back, it can spread through your respiratory droplets, but really it can also spread through the rash. And the blisters contain a lot of virus, so scratching it puts it on the fingers, but mainly it's spread through the air.

Host Amber Smith: How long have you been studying Varicella zoster virus? This has been your whole career, right?

Jennifer Moffat, PhD: Yes, 30 years ago, at this time of year, is when I started my postdoctoral fellowship (specialized training) to work on a new thing for me, which was this virus. I was at Stanford University Medical Center in the pediatric infectious diseases department.

It really set me off. I just took it and never let go. So I've been building up a lot of research years, 30 years now, and it's a small field, so I'm more and more considered one of the world experts.

Host Amber Smith: Well, let's talk, if we can, about how chickenpox is related to shingles. Can you describe both of the diseases, how they're contracted and how they are similar?

Jennifer Moffat, PhD: Yeah. Well, we all are familiar with chickenpox, mainly as a childhood disease. And its official disease name is varicella. So that's the first half of this virus's name. Varicella is chickenpox, and kids spread it, from one kid to the other, in families, classrooms and so on. And we were all familiar with the rashes and so on.

It wasn't known until the '50s, really, that shingles was the same virus that popped out in adults. And the other name for shingles is zoster. So the Varicella zoster virus is now known as the one that causes both. It's the same virus. So when a child is infected, from their playmates and siblings, the virus infects their nervous system immediately. So even before the rash pops up, during the incubation phase, the virus enters the nervous system, where it infects the nerves that are along the spine, the dorsal root ganglia. And it stays there forever. And our immune system then quiets things down. We get better when immune to the virus quite well during young adulthood.

And this immunity is important to keep the virus from popping back out. So in any situation where immunity dwindles either from medical reasons, health reasons or age, the virus says, "Ah, here's my chance." And it comes roaring back from the nerves out to the skin. And that can be mainly on the chest, the back and the face.

A third of shingles cases are on the face, and then that's the eyes, the ears, the mouth -- very sensitive areas, but it is the same virus. And you can't actually catch shingles. It comes from inside of us. So you can't catch it from another person who has shingles. If you've had chickenpox or been vaccinated against it, the only way you can get shingles is from the viruses already inside you.

Host Amber Smith: So if you, as a child, you never had chickenpox, then you shouldn't have a risk for shingles?

Jennifer Moffat, PhD: That's right. There is a risk, though, if you've never had chickenpox and never had a vaccine for it, and you've never encountered this virus, the older you are, if you do get it, the more dangerous it is. So chickenpox in kids used to put 10,000 kids a year in the hospital and killed even 100 kids a year, on average. That's all different now in the age of the vaccine, but adults who got it were very seriously ill, and more adults died than kids. So it's a good idea to get immunity to it with a vaccine as a child or get infected, which happens in a lot of countries.

Host Amber Smith: So a person who was vaccinated against chickenpox, should they also get a shingles vaccine when they reach the age for that?

Jennifer Moffat, PhD: Yeah. The chickenpox vaccine was one of the things I worked on 30 years ago, and it was approved in 1995. So the children who got it then are approaching 28, 29 years old.

They're not really old enough to worry about shingles, but when they are 50, they will definitely be eligible for the Shingrix vaccine or any new vaccine.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking with Dr. Jennifer Moffat. She's an associate professor of microbiology and immunology at Upstate, and she specializes in the study of the Varicella zoster virus, which causes chickenpox and shingles.

So why are there more cases appearing in people under 50 with shingles, people that are even in their 20s, 30s, 40s that are getting shingles? What is the current hypothesis for why that's happening?

Jennifer Moffat, PhD: Yeah, that is a great question, Amber, and we aren't sure, so we still have more questions than answers on this one, but what we know is, everywhere around the world, the cases and the incidence, we call it, the rate or the number of cases per population, is rising for shingles.

We don't know why, and it's not necessarily linked to just an aging population. That's one idea: "Oh, we're just all getting a bit older, so there's more shingles." Well, yes, we get more shingles when we're old, but that doesn't account for what we're seeing, which is people younger -- 20s, 30s, 40s and 50s -- are now getting shingles more often.

And what could that be about? A lot of thoughts. OK, so we know that if the immune system is weakened, the virus can pop out, so that might be something going on. Maybe overall, our immune systems aren't in great shape, but that can't explain all of this.

Maybe we're taking more medications like steroids or immunosuppressant drugs that raises the risk. Maybe people are less healthy, right? We have epidemics of other diseases. Maybe it's linked to that. But we've tried to rule all of these things out, and what we're left with is still scratching our heads and thinking, "What on earth is causing this? Is it just doctors diagnose it better now? We have better medical care, people go to the doctor more?" Those could all be parts of it.

But what we're leaning toward is almost a global change in our human/virus balance, and it could be something very subtle like air pollution or sunlight or temperature. We don't know. We're hopeful to solve it, but we can't say today why we see more virus.

Host Amber Smith: How is the disease different in a young person compared with someone over 50?

Jennifer Moffat, PhD: Luckily, young people have less serious outbreaks of shingles. When they get it, it's a lot less concerning. It doesn't last as long, it doesn't create such a large rash, and it will often heal just fine on its own.

However, that's not the case the older we are. The risks we're worried about are the virus comes out of nerves, and when it does that, it can really irritate the nerves, and it can then cause nerve damage and pain, long-lasting pain, from those nerves called postherpetic neuralgia, or PHN, devastating, painful, can last for years or more. And young people just rarely experience that lingering pain. So that's the major difference, the seriousness of it.

Host Amber Smith: Well, let's talk about what can be done to protect people from chickenpox and shingles. Are pediatricians still vaccinating children against chickenpox?

Is that still a recommended vaccine?

Jennifer Moffat, PhD: It is recommended. It is recommended by the CDC (Centers for Disease Control and Prevention) (Advisory) Committee on Immunization Practices, and it's also mandated by the state of New York. So the 1-year-old children will get their first dose, and then again, usually right around the start of school, between age 4 and 6. This has been fantastic to prevent outbreaks of chickenpox in the schools and day care.

So what we don't see anymore is this normal springtime wave of chickenpox. That is not happening. The whole epidemiology (occurrence) of this infection has changed due to vaccination.

Host Amber Smith: If there is someone who got through childhood without being vaccinated, is it too late to get the vaccine as an adult?

Jennifer Moffat, PhD: No, it's not. We screen all of our incoming staff at Upstate Hospital. At University Hospital, if you get a job here, you will be screened for your immunity to chickenpox. And every year we find adults who are not immune, and they get the vaccine in our employee health (department). And that is a good idea to protect them. The patients who have shingles could infect them and give them chickenpox.

Host Amber Smith: Well, what are the vaccination rates for shingles for people over age 50? I think that that's when they're recommended, 50 and up, right?

Jennifer Moffat, PhD: Yeah. The vaccine that's used in America right now is called Shingrix, and it is highly effective, 95% effective, at preventing shingles. Well, that's too bad, because only 30% or so of people who are eligible have even gotten it. So that's not enough. We could do better.

And people are sick and tired of vaccines, right? Like, "Enough already. I've had all those shots." But Shingrix is one that you probably don't want to put off because once you turn 50, you're eligible, and it's a two-dose vaccine. It does hurt. People say the arm is real sore, but it's worth it because shingles is so much worse, and the lingering pain is no joke. And the virus, when it reactivates in their eyes, can be blinding, and that's terrible.

Host Amber Smith: And is that a one-time vaccine at age 50?

You don't have to repeat it later?

Jennifer Moffat, PhD: You do. It's a two-dose regimen, but you don't have to repeat it. It's one dose, and then you need the second dose two months to six months later.

Host Amber Smith: And then you're good for life.

Jennifer Moffat, PhD: Yes. Then you're very good. It's like a booster. So the Shingrix vaccine is interesting in that it's the only approved vaccine right now that's designed as a booster for people who are already immune, who already had chickenpox or the Varicella vaccine.

So the Shingrix is designed as a booster, so you really just need that one boost right in your 50s.

Host Amber Smith: Now if we're seeing this show up in people in their 20s and 30s and 40s, is there any thought to vaccinate these people at younger than 50?

Jennifer Moffat, PhD: Well, it comes up; we talk about this in the field all the time, and we're thinking, "Why don't we give people a booster at 30 and get them through to 50?"

And that just hasn't been studied. There hasn't been a clinical trial to study that question. But now that Shingrix is approved, some doctors are recommending to their patients, they're saying, "Hey, you have a particularly high risk for shingles. Let's give you the vaccine." And those are people with underlying health conditions that raise their risk of shingles. And if they have a really smart doctor, they will recommend that they get it as a younger person. But that isn't routine right now. But that could change, and it just requires more research.

Host Amber Smith: Do you have any personal experience with shingles?

Jennifer Moffat, PhD: Well, regrettably, yes. It's ironic, isn't it, that I work on this virus, and I've actually had it twice.

As a young woman, I had a tooth infection, and the infection under my filling triggered shingles on the left side of my face, and it was so mysterious. I didn't know what was wrong at first, but eventually it was very clear that I had shingles from the tip of my nose into my ear, and that was very uncomfortable. I suffered a lot.

So it did heal, and everything seemed fine. And then again, during the COVID epidemic, I got my first COVID vaccine and then the second, and then I got shingles right after that. And it turns out, they found out now that there's a higher risk of shingles right after getting other vaccines.

So I got it again in that same place on my face, and it went into my ear and caused ear pain for a couple of years. So it was definitely worse the second time. I felt like a dummy. You know, (chuckles) here I am, I should have had my Shingrix shot, but, of course, I hadn't, and then I regretted that a lot.

Host Amber Smith: Well, the Shingrix, that wasn't available until when?

Jennifer Moffat, PhD: 2018.

Host Amber Smith: When you were in your 30s, it probably didn't exist, right?

Jennifer Moffat, PhD: It did not exist. No. But later, I was overdue for my Shingrix vaccine and regretted putting it off.

Host Amber Smith: Well, good advice then. Thank you.

Getting back to the virus itself, I'm curious about what is still being studied about it, and what more is left to learn?

Jennifer Moffat, PhD: Oh, well, (chuckles) I have a very busy laboratory here at Upstate, and my emphasis is on discovering and testing new antiviral drugs to treat shingles. Despite the vaccine, we still have a million cases a year of shingles, and people are desperate for treatment, something that you could either take a pill or spread on an ointment, but something to speed healing, reduce the risk of pain, heal the rash, all of those things.

So I have a lot of work to do with, companies and labs around the world who send me their compounds to test them, to see if we can stop some shingles right on the skin.

Host Amber Smith: Very interesting. Well, Dr. Moffat, thank you so much for making time to tell us about your work.

Jennifer Moffat, PhD: Oh, it's been my pleasure, Amber. I just think there's a lot of new discoveries still left to be done.

Host Amber Smith: My guest has been Dr. Jennifer Moffat from the department of microbiology and immunology at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air

Low back pain, causes and treatments? Next on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York. I'm Amber Smith. This is "HealthLink on Air". If you've injured your back and all you want to do is rest, you might be doing the wrong thing. Today I'll talk about physical therapy treatment for low back pain with someone from Upstate who specializes in strength and conditioning. Steve Lounsbury is a doctor of physical therapy.

Welcome to "HealthLink on Air," Dr. Lounsbury.

Steven Lounsbury, DPT: Thank you very much. Thank you for having me.

Host Amber Smith: If someone strains their back or feels like they've pulled a muscle and it hurts to move or bend, what would you tell them to do?

Steven Lounsbury, DPT: I would say in the case of an acute injury -- in our world, that's usually within the first two weeks -- the best kind of treatment for it is to stay active, to stay mobile. Our spines are made to move, and we feel better with movement. I often teach my patients the phrase that "movement is medicine."

Host Amber Smith: So even if it hurts, you still have to stay somewhat mobile. Do you recommend ice or heat for the pain?

Steven Lounsbury, DPT: Typically in the acute phase, that early zero to two weeks, I tend to tell people that there is an inflammatory process going on, that inflammation that usually follows an injury, so ice tends to feel better.

However, once we're out of that early period, whichever one feels better for their particular symptoms is what I go with. There is no strong evidence either direction after that acute phase.

Host Amber Smith: Are there different recommendations for children versus adults versus senior citizens?

Steven Lounsbury, DPT: Not necessarily. What we base our treatment guidelines on are actually called clinical practice guidelines, and there are a set of documents that our governing body has developed over decades of research.

They're continuously being updated. And they develop them with the concepts in mind of treating across the lifespan. And we focus less on the age group affected by the injury and more specifically about the stage of injury they're in, that acute versus chronic stage.

Host Amber Smith: Is there a difference between if it's lower back versus midback or upper back?

Steven Lounsbury, DPT: There is slight differences in the way we approach treatment. However, the generic concepts remain the same for how we approach movement, encouraging mobility or the ability to move through different ranges of motion, as well as strengthening of all the supportive muscles around the affected area.

Host Amber Smith: So what happens if someone doesn't heed this advice, and they decide they're going to rest anyway because they're in pain and they're going to lay on the sofa until they start feeling better? Are they making things worse for themselves? Are they dragging it out?

Steven Lounsbury, DPT: I wouldn't say the term "making it worse," so much as delaying their recovery. Typically when we have periods of immobility or not moving around, we tend to feel worse anyway. Again, our spines are made for movement. We feel better when we change postures throughout the day when we do different activities throughout the day.

There is such a thing as overdoing it in the acute phase, but more often than not, light activity such as walking or light household work is perfectly fine.

Host Amber Smith: How does a person know if they need to see a doctor about an injury?

Steven Lounsbury, DPT: So as a broader concept, it's tough to identify when you need to seek care, whether from your primary care physician or directly from a physical therapist. I would usually tell people if it is something that is not changing in the level of severity or how intense the pain is or the symptoms are for about one week of time, it might be time to consider that consultation with one of your doctors or a physical therapist.

Host Amber Smith: So let's talk about what role physical therapy can play in treating acute back pain. Would you ideally want to see a patient soon after the injury, or do you want them to wait and see if things get better or if they change without intervention?

Steven Lounsbury, DPT: So I would actually prefer to see the individual or the patient as soon as possible after an injury, for several reasons. One, because in those clinical practice guidelines I mentioned earlier, we do have a lot of good evidence for treatment techniques early on in the injury and recovery process.

And secondly, because the injury likely occurred for some underlying reason, whether it was improper lifting technique or weakness in target muscles that we would rather are stronger can take the load away from the spine, there's usually that underlying cause that we can help to address to prevent this from happening again.

Host Amber Smith: For someone who's never had PT, what can they expect?

Steven Lounsbury, DPT: So physical therapy is not a one-size-fits-all generic treatment. There is no magic pill to it. Every physical therapy session that you would receive through somewhere like Upstate is led by a licensed doctor of physical therapy. . We are a doctorate level profession who goes through a long course of schooling, across a wide domain of different specialties and ways of assessing different systems.

And when you come see a doctor of physical therapy, our treatments involve many different approaches. It's called a multimodal approach. So sometime there is heat, or sometimes there's hands on mobilization or manipulation of the spine or the joints. There's a lot of therapeutic exercise, which is targeted strengthening and stretching of the muscles in the area of the injury.

And quite often what we also look at is not only the immediately affected area, but also adjacent areas or areas near to the injury, because we operate on this concept that one area affects the next one. It's that old song, "The head bone's connected to the neck bone." It's just a lot more complicated than that.

Host Amber Smith: So if a person wants to see a physical therapist, they don't necessarily have to ask their primary care provider. They can just call the physical therapist directly, is that right?

Steven Lounsbury, DPT: In New York state, we operate under a term called direct access, which means that a patient can just walk in from the street and see a doctor of physical therapy for either 30 days or 10 treatment visits, whichever occurs first before they're required to have a script or a referral from their primary care doctor or an orthopedic doctor.

Unfortunately, at Upstate we are unable to do that, per our accrediting body guidelines. We do require that script or referral.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Dr. Steve Lounsbury. He's a doctor of physical therapy specializing in strength and conditioning, and we're talking about the role of physical therapy to treat low back pain.

Is everyone a candidate for physical therapy, or is there any person who would not be a good candidate for physical therapy?

Steven Lounsbury, DPT: That's a good question to bring up and a good moment to talk about what we would call red flags in the medical community. These are signs or symptoms that might suggest you need further medical assessment rather than treatment from a physical therapist.

They might suggest some more serious underlying pathology or other condition that might be explaining why your back pain is persistent. And those could be multiple. We won't dive into all of them today. But the red flags that I'm usually looking for is something more systemic, like fevers and chills, a change in sensation in the region of your groin, what we usually call a saddle area, if you were sitting on the saddle of a horse, any kind of sudden unexplained weight loss recently, especially if it was unintentional, pain at nighttime or at rest that does not change with a change in position, a failure to improve over the course of about one month, and there are many more. We could keep going for a while. But there are certain red flags like that that would say to either your primary care doctor or if you are being seen by a physical therapist, we're trained to recognize those to say, PT might not be the most effective treatment at this moment, and you should seek further medical attention.

Host Amber Smith: So it sounds like you look at like the whole patient, not just where their pain is, but you look at them as a whole person and try to figure out what else might be going on.

Steven Lounsbury, DPT: Absolutely.

Host Amber Smith: So are the exercises that you prescribe, are they meant to relieve the pain or prevent further injury?

Steven Lounsbury, DPT: Yes, to both. And the approach to treatment changes slightly depending on the individual patient in front of you. And I think this is where the nuance of what physical therapy is as an art and a science kind of meets in the middle to say that if we've had pain for only a couple of weeks, my goal is to help you get completely out of that pain, to eliminate it entirely, and then to prevent it recurring in the future or happening again.

However, if this is something that's been going on for a couple of decades, you've lived with chronic back pain for 20-plus years, we know per all the research that we've done that the pain is unlikely to ever go away entirely at that point. There are changes in the brain that mean you're more sensitive to that pain now, and it's likely to be lasting.

But what we can do is take you from, let's use our typical numeric rating scale of zero to 10, 10 being the worst pain you've ever felt, and zero being no problem. If I have a patient who's had 20-plus years of back pain and they come in at an 8 out of 10, well, I would see success if we could bring them down to a 2 or 3 out of 10, knowing that the pain is still there, but we've given them ways to manage that on their own and be more active, accomplish what they might want to do.

Host Amber Smith: So when a person comes for physical therapy, they're going to be active, right? I'm just wondering, do they need to dress like they're going to a gym?

Steven Lounsbury, DPT: Yes. That is typically something that we do run into on occasion. We know it is tough because quite often you are coming to physical therapy from work or from picking up your kids or from anything else. It does make it harder depending on, especially if we're looking at your low back, if you're wearing clothing that doesn't allow us access to at least visualize your low back or see it, and we are pretty good about draping with towels and stuff like that to maintain a patient's modesty, of course. But it is nice to have exercise clothes. It allows you greater freedom of movement.

So for men, if you're wearing a dress shirt that's tucked in very tightly, it might be tough to assess how far you can truly move if the shirt is what's limiting you. For females, showing up with either a skirt on or leggings or jeans that might restrict your movement of your lower legs, that might also be an issue. Because like I mentioned, when we look at the low spine, we're also considering the role of the hips, the knees, the feet, and how they play into that.

Host Amber Smith: So for someone with an acute pain injury, how soon might they expect to notice improvement?

Steven Lounsbury, DPT: There are a couple different ways of noticing improvement. One, in terms of pain relief. Hopefully we can achieve something within a session, especially if it is that acute. Most of our treatment that we apply, especially for acute injuries, is focused on quick reduction of that pain. We don't want to let it become something chronic or disabling for the long term. We want to try and get you out of that moment of pain and discomfort as soon as possible. So hopefully within the first session or two, they would start to realize that there is some pain relief.

Building strength takes a little bit longer. That's a matter of weeks as we go. Usually, I would like to tell patients that a clinically meaningful change in their strength -- meaning something they'll notice the difference in their daily life, not just something we could measure with a tool here --will take on average, about six weeks to start to be noticeable to the patient. It is a slow initial curve and then it speeds up over time.

Host Amber Smith: So your relationship with a patient might last a period of weeks or months typically, is that right?

Steven Lounsbury, DPT: Correct.

Host Amber Smith: Well, we've been talking mostly about acute pain from recent injuries, but you did mention, people with chronic pain. Can they still get some relief? Have you seen that work for people through physical therapy?

Steven Lounsbury, DPT: I certainly have. We have quite a large percentage of our treatment caseload that we see that is chronic back pain. In fact, one of the leading causes of disability worldwide is chronic back pain. It's the sixth most costly condition in the U.S.

And one of those things that we try to do, like I mentioned earlier, is focus on not only relieving some amount of pain, but finding ways for them to manage it throughout their day. Some of that might be setting reminders on their phone to be up and be moving for a certain period of time if they sit for work. It might be teaching exercises to maintain mobility every morning, every evening, because if we think about sleep as the longest period of inactivity in our day. Where we're largely in the same position, that's when most people feel worse. It's late at night and first thing at the morning.

Host Amber Smith: Oh, that's a good point. I wanted to ask you about massage. Have you ever seen that helping someone with acute back pain?

Steven Lounsbury, DPT: I certainly have, and it's actually one of those recommended interventions we have within our clinical practice guidelines. We are not massage therapists. That is a separate profession. However, we can utilize soft tissue massage or soft tissue manipulation. It is skills that most physical therapists have been trained in rather extensively. Everybody entering the field has some amount of training in it. You can go on to do continuing education within that area as well. So it is typically one of those treatments we'll apply early on for an acute injury.

Host Amber Smith: Are there stretches or movements that you would recommend that people can do regularly to strengthen their backs and then hopefully prevent injury in the first place?

Steven Lounsbury, DPT: There is no particular movement because it is so patient specific. Speaking in a generic sense, trying to get out of the forward bent posture that most of us spend the day in, typing, writing, driving, cooking, cleaning, everything is largely in front of our body. I made a joke when I had a community presentation last night that we don't often dice an onion or fold laundry behind our back. So most of us spend the day very forward and rounded with our shoulders. Our chin creeps forward. So working on bringing ourselves up out of that position helps to relieve some of the back pain that comes just from being in one position for too long.

Host Amber Smith: Well, that's really good to know. Thank you so much for making time for this interview, Dr. Lounsbury.

Steven Lounsbury, DPT: Thank you very much for having me.

Host Amber Smith: My guest has been doctor of physical therapy Steven Lounsbury from Upstate Medical University. I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air" -- how using cannabis can reduce your tolerance for pain.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink On Air."

Many people who use cannabis for medical reasons are seeking pain relief. Medical cannabis is currently used as an off-label pain treatment without Food and Drug Administration approval. Is cannabis a natural herb that is safe to use? Today I'll be talking about risks that may be associated with the daily use of cannabis with two guests. Dr. Brian Johnson is a clinical professor emeritus of psychiatry and behavioral sciences and the recently retired director of addiction medicine at Upstate, and Dr. Yanli Zhang-James is a research associate professor of psychiatry and behavioral sciences at Upstate.

Welcome, both of you, to "HealthLink on Air."

Yanli Zhang-James, MD, PhD: Thank you, Amber. Good to be here.

Host Amber Smith: Your research was published in the American Journal of Addictions. Let's start with your conclusion first, and then talk about how you got there. You say that daily cannabis use may make chronic pain worse over time, by reducing pain tolerance, so that people who use cannabis daily may be risking addiction without long-term benefit for chronic pain. Is that right?

Yanli Zhang-James, MD, PhD: That's absolutely correct, Amber. That's the most important message that we wanted to convey through this study.

Reduced tolerance to pain is not new for other drugs like opioids, alcohol and nicotine. But it's a first time that we reported that this also happens to people who chronically use cannabis. And this is really important because it's becoming increasingly widely accepted and considered relatively safe drugs to use for pain, but people should still be aware that it comes with certain risks, like we showed.

And I do want to highlight that one of the most important things that made the study possible is the incorporation of cold pressor time tests into the clinical practice that Dr. Johnson had for over 10 years at the department of psychiatry. This was a pain service. He saw over 2,000 patients with all kinds of pain and various addictions. So with almost all of the patients that he had tested for cold pressor time, which is an objective measure of their pain tolerance, and we were able to see that for people who use cannabis chronically, that this system is also compromised.

Host Amber Smith: Let me, if I may... You mentioned the cold pressor test. Dr. Johnson, can you explain what that is and how it's done?

Brian Johnson, MD: It's a fancy name for a very simple procedure. It's a beer cooler full of ice water. There's an aquarium circulating pump. The patient puts their completely normal forearm in, and it really hurts. And then we just time how long the patient is able to keep their arm under the ice.

Host Amber Smith: Interesting. Very simple to understand. Now, for this study, you were focused on people who were using cannabis for chronic pain. Does that mean, would it be treated differently if someone was using it for acute pain?

Brian Johnson, MD: Yes. It's called opponent process. And it's true of alcohol, nicotine and opioids, as well as marijuana. Anything that reduces pain short term increases it if you use it constantly.

Host Amber Smith: Dr. Zhang-James, how many patients were included in this study, and over what period of time were you focused on?

Yanli Zhang-James, MD, PhD: So, this is a retrospective review of patient medical records. We had records from over 10 years, so we had over 2,000 patients total. It was difficult to find people who only used cannabis without other drugs, but we were able to find 47 that had used the cannabis, without opioid or alcohol. Thirty-seven of them also used nicotine. So in order to tease apart that effect, fortunately we were able to find also 32 patients who used only nicotine, no cannabis, and no any other drugs. And we were also able to find 30 of them who had actually did not use any of these drugs. So it is a relatively small study, but we were able to see the effect. And definitely would be interesting (to see) future studies that can replicate this finding in a larger sample size.

Host Amber Smith: Let me ask you, I don't understand why you included tobacco use, or nicotine. What difference does that make or what impact does that have? Dr. Johnson?

Brian Johnson, MD: This is a little-known thing, but we've got wonderful colleagues at Syracuse University who are important researchers on nicotine and pain. So, Professor Joe Ditre would be the leader of that group, and they've published several studies showing that if you inhale tobacco, you've got more pain.

Host Amber Smith: Interesting.

Brian Johnson, MD: The context here is, we've got a database of about 2, 000 patients who came to the pain service, and we were so careful to find people who only used nicotine, only used marijuana. Of course using marijuana and nicotine together is common, so that was the third group. And then we could only find 30 people who did not have a history of exposure to any addictive drugs.

Host Amber Smith: Did the cannabis users in your study ingest the cannabis by smoking?

Brian Johnson, MD: Yes. Eating marijuana is unusual in our population. Most people inhale the drug, and of course, that's a weird route of administration. I'm always saying, when you take an aspirin for pain, do you smoke it, inject it, snort it, or eat it? Almost everyone eats their drugs. To use your lung to get drugs into your brain is just weird.

Host Amber Smith: Well, you looked at daily cannabis use. How much cannabis were they using though, daily?

Brian Johnson, MD: OK, so this is another thing about studies. Studies don't indicate anything about one particular person. We've got to agglomerate people into categories. So if you used one joint or if you had two joints for breakfast, two blunts (marijuana cigars) for lunch, and five cigars full of marijuana for dinner, you went into the "daily use" category.

Host Amber Smith: This is Upstate's "HealthLink On Air" with your host, Amber Smith. I'm talking with Dr. Brian Johnson and Dr. Yanli Zhang-James, who both work in Upstate's department of psychiatry and behavioral sciences, and we're talking about whether daily use of cannabis provides chronic pain relief.

Now, Dr. Johnson, can you explain how the body develops hyperalgesia?

Brian Johnson, MD: OK, well, one idea to mention is just like the way we got to daily marijuana use is daily opioid use. Every drug that comes from a plant -- so of course, nicotine comes from the tobacco plant; morphine comes from the poppy plant; and marijuana comes from the marijuana plant -- these are natural substances. And we all make hormones, we make cannabinoids, we make nicotinic acetylcholine, and we make endogenous morphine or endorphins. That's why we've got a receptor system. When you pour huge amounts of these hormones into your body by either taking opioid medications, inhaling cigarettes or marijuana, you change the receptor system.

Host Amber Smith: Dr. Zhang-James, does that receptor system, does that mean that all types of pain are going to be affected, then? Not just the chronic pain that the person has, but, for instance, if they get a paper cut, is that going to hurt more because they've become more sensitized? Is that how that works?

Yanli Zhang-James, MD, PhD: Yes. In some sense, yes, exactly, because all the pains that we receive from peripheral stimulations -- either it's headache or muscle ache, injury, post-surgical pain or paper cuts -- all mediated through our brain's central pain system.

We don't know exactly how different drugs act on this, but we do know that when the system gets sensitized and when patients have reduced tolerance, all kinds of pains get amplified. That is actually why we were able to use cold pressor time to measure the health of the central pain system.

Host Amber Smith: How soon after you start using marijuana on a daily basis, is this likely to develop, where you have this increased sensitivity?

Brian Johnson, MD: No one knows. We just discovered this. So, if we had a million dollars, we could take people and have them start to use marijuana or placebo and answer your question. But all we can tell you right now is anything that helps with pain short term is going to worsen it long term.

Host Amber Smith: What if a person stops taking cannabis? Will their pain sensitivity, will it go back, or is the damage done already?

Brian Johnson, MD: Same answer. We just discovered this.

So we can answer that about opioids. And unfortunately, a lot of opioid-induced hyperalgesia looks like it's permanent. Other people seem to get better over months and years. So the message here is: Be careful. Don't use something that helps your pain every day. You want to use it once in a while. You want to take an oxycodone to help you sleep because your back is really hurting -- fine. You want to smoke a joint -- no problem. Just be careful that drugs that you use frequently cause this opponent process.

Host Amber Smith: A lot of patients and even medical providers are seeing cannabis as a treatment for pain. Is there evidence showing that it can help with that? Or, where did they get the idea of using cannabis for pain control in the first place?

Brian Johnson, MD: Well, it's a flavor-of-the-week phenomenon. You know, anything that makes you feel good should be good for everything, right?

But unfortunately, it's like opioids were 20 years ago. Everyone was saying, gee, we've got a great drug, Oxycontin, that is magnificent for pain. Everyone should be on it. Twenty years later, unfortunately, they're saying the same thing about marijuana.

Are there good long-term studies? There are a few. Ours is one, and we could find four other studies, and they all show the same thing.

Host Amber Smith: Are recreational users of cannabis likely to develop increased pain sensitivity also, just like the daily users?

Brian Johnson, MD: Yes, it happens. If you use heroin for fun, or if you use heroin because your back hurts, you're going to do the same thing to your brain. And that's true of marijuana too. If you use it every day or frequently, you're going to attack your own pain dampening cannabinoid system, and you're going to make more pain for yourself.

Host Amber Smith: Well, what do you recommend be done for patients who have chronic pain and have been using cannabis daily, and now they've got this increased pain sensitivity. What can be done for them?

Brian Johnson, MD: They should come to our addiction medicine service. It's terrific. It uses the cold pressor test. Psychotherapy is the main modality of treatment, but we can treat anything else. If you've got anxiety, pain, depression, ADHD (Attention-deficit/hyperactivity disorder), those are immediately recognized and treated along with your pain. So just call up (315) 464 3130 and make an intake appointment and get some expert feedback.

Host Amber Smith: I appreciate both of you making time for this interview.

Brian Johnson, MD: Well, thank you for having us.

Yanli Zhang-James, MD, PhD: Thank you.

Host Amber Smith: My guests have been Dr. Brian Johnson, a clinical professor emeritus of psychiatry and behavioral sciences, and Dr. Yanli Zhang-James, a research associate professor of psychiatry and behavioral sciences at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

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Deirdre Neilen, PhD: COVID continues to be a focal point for many writers. We received excellent poems from physicians describing some of their experiences with it. The first poem I'd like to read is by fourth-year medical student Ellen Zhang. She is a student at Harvard, and her poem "To Open Doors" won our Sean Hodge Prize for Poetry in Medicine this year.

"To Open Doors"

Your arrival reminds me of what it means to care

in the moment. It was not the way you weighed

merely two pounds, the way you necessitated

emergency surgery, or the way you gripped

onto life even though it caught you off guard.

It was the way your mother broke rumbling

of the monitors, wrapped in mask and goggles,

wearing gloves to cradle you. Asking for you to be

loved for the first time by grandparents, uncles,

aunts, cousins. To be loved for a long, long time.

In hospitals, so many bodies share the

same air. In times of pandemic, supplies are

lacking, regulations proliferative. Your ribs

barely rise to fall. Reminders that oxygen is

a scarce resource. But, love, love is plentiful.

Dr. Sarath Reddy is a gastroenterologist practicing in Brookline, Massachusetts. His poem "Unfinished Conversation" recalls the impact some patients can have on us.

The virus left his lungs moth eaten,

parched leaves crumbling to touch

unable to bear the work of breathing,

until machine, not man, was driving life.

Desk shrouded in silence, a friend taken

for granted like scenery, I sketch him

back in, give him back his Greek accent,

staccato on the computer.

As he bounces between topics, musings

on chili pepper and menu of India Delight

spicy samosas and vindaloo,

brought him back

long enough to say I'm sorry --

that I could give him only prayers

and not potions, had reluctantly lent

his obituary a pen,

that we never spoke about God or Plato

never got beyond headlines, whimsical weather,

and pleasantries

just like trees regret never asking autumn

leaves the questions that really matter.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

Next week on "HealthLink on Air," what to expect after a breast cancer diagnosis.

If you you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe with sound engineering by Bill Broeckel.

This is your host, Amber Smith, thanking you for listening.